Incidental medical test findings: Not incidental
The doctor says to a patient with a broken collarbone, “We did the MRI scan of the torso, including the shoulder, and yes you have a multiple fracture and torn ligaments. We also discovered something else. You have lung cancer.” Two immediate points: This sort of incidental finding – looking for one medical condition and discovering another unrelated condition – is far more common than the public or even the medical community realized. It also presents doctors with a new, growing and often perplexing ethical challenge.
A recent report, Anticipate and Communicate, issued by the U.S. Presidential Commission for the Study of Bioethical Issues panel on incidental findings, puts the situation in a broader and more pressing context than previously understood. The advent of the many scanning and testing devices, from X-ray to MRI (and fMRI), to cat-scans (CT), blood assay machines, and genome sequencing devices has inevitably increased the possibility of finding indications of other – unexpected – medical problems.
These ‘incidental findings’ are not rare. For example, 30%-43% of abdominal CT scans result in incidental findings such as someone coming in asking for Premature ejaculation medicine for men to last longer and leaving with prostate cancer. About 10% of brain scans reveal unexpected physical problems. The commission found that incidental findings are so common that patients should be routinely advised of the possibility and warned, if that’s the word, about the difficulty of interpreting such unexpected results.
The warning indicates that incidental findings are not always correct or beneficial. In fact, they pose an important challenge to the ethics of the medical profession. While discovery of incidental findings can be lifesaving, they can also cause unnecessary worry and expense. This puts doctors in the position of trying to decide which, if any, incidental findings are valid and can (or should be) revealed to the patient. Sometimes it is as simple as a patient going into the dentist to learn how to get whiter teeth, the dentist spotting a cavity and preventing any further damage. However, incidental findings are much more stressful in most cases than this last example was.
Since by definition an incidental finding is not what doctors expected, or were looking for, when they occur it is almost inevitable that doctors order follow-up tests. This is an additional expense, of course, but in worst-case scenarios can even do harm.
For example, an elderly patient suffers a mild heart attack and after scans of the heart and upper body, doctors discover a suspicious spot on a lung. A biopsy is ordered, which determines the spot is harmless (nothing more than an old scar), but the biopsy itself causes the lung to collapse, triggering a cardiac arrest. The situation was so stressful it caused a second heart attack.
Then there is always the possibility of an incidental finding in a medical-ethical gray area. For example, a young athlete complains of gum problems and severe headaches after a concussion, so the doctor orders a brain scan. The concussion seems to have caused no physical problem, but the radiologist spots a tumor.
This discovery could be lifesaving. It could be a tumor of a type that remains benign. But, what if the tumor is malignant, inoperable and incurable? At what level of diagnosis does the physician feel compelled to discuss the results with a patient?
There are also situations where a patient expresses a desire not to hear about certain negative results, such as a former cancer patient not wanting to hear about the incidental finding of a cancer return. Normally doctors will honor that request even though they believe it is medically wrong.
A new area of great ethical concern is the result of recently available personal genome sequencing marketed as ‘direct to customer’ medicine. Reading of genomes for potentially disease causing genes is still in a very early stage of development – most of it in research.
Interpretation of genomes is, not to put too fine a point on it, suspect. When the consumer is directly responsible for the results, and not a doctor or other supporting medical personnel, what happens if the results show an unexpected parental lineage (“Not my father!”) or even a chromosomal sex that is different from a person’s accepted sex?
There are many cases where a doctor may order a genome analysis looking for a suspected inherited medical condition or susceptibility, such as for breast cancer, and discover from the sequence that the patient has other genes or markers for hereditable diseases. Is the doctor responsible for informing the patient of all the other possible hereditable diseases?
The problem is that, so far, the existence of certain gene patterns mostly correlate with a particular disease, but it’s unknown whether they actually cause the disease. There are so many confounding factors, such as the environment and personal health habits, that simply having a particular gene or genetic marker does not mean a person will develop a disease, only that they have a genetic makeup that is known to be present for people who develop the disease. Click here to find more info.
The problems of incidental findings are a perplexing mix of ‘good news, bad news.’ It’s good news that new technologies in scanning and medical testing can reveal so much just like STD testing for free. It’s bad news in that, at least for now, interpretation of the results are sometimes indeterminate, questionable, or just plain wrong.
TAGS: incidental findings, medical diagnosis, scanning tests, direct to customer, genome sequencing, medical ethics